JAMA Article Slams Mammography: At What Cost?

When JAMA published an opinion piece¹ in October 2009 questioning the effectiveness of mammography screening and calling for new screening protocols to separate life-threatening cancers from less harmful lesions, the mammography community reacted with alarm. Lawrence Bassett, MD, FACR, Iris Cantor professor of breast imaging at the David Geffen School of Medicine at the University of California Los Angeles, says that the takeaway message for patients could be that because mammography is imperfect, exams can be skipped. Such a response would be very dangerous, he notes. “Women might use this as an excuse not to get mammograms,” he says. Ellen B. Mendelson, MD, professor of radiology and section chief of breast imaging at Northwestern Memorial Hospital, Chicago, Illinois, is equally adamant that women must continue to get mammograms according to current guidelines, despite the concerns raised in the JAMA article by Laura Esserman, MD, MBA, a professor of surgery and radiology at the University of California San Francisco, and her coauthors. “One suggestion by Esserman should not be taken as the last word; it would be completely wrong,” Mendelson says. “If she wants a new path, fine, but until that path ends in something documented, there should be no change. This is serious,” Mendelson adds. “This whole edifice of breast-cancer screening took decades. Nothing should change.” Bassett says that women don’t need another reason to put off a mammogram. “No one wants to deal with going in to find a breast cancer,” he says. “Some women are very scared each time they go, and they want the results right away, even though it only takes a day or so.” Not only is a woman’s sexual image at risk from breast cancer, Bassett adds, but the thought that cancer could kill her in the midst of her childrearing years is even more frightening. “We found that in a study we did on breast biopsies,” he says. Faulty Conclusions Bassett says that he was more upset about news coverage of the JAMA article than he was by the article itself. Particularly troublesome was an October 21 New York Times article² indicating that the American Cancer Society (ACS) might revise its mammography guidelines, Bassett says, because the article was inaccurate. In a letter, the ACS has called for women to continue breast screening. “The test is beneficial in that it saves lives, but it is not perfect. It can miss cancers that need treatment, and in some cases finds disease that does not need treatment,” Otis W. Brawley, MD, chief medical officer of the ACS, writes. “Understanding these limitations will help researchers develop better screening tests.” He adds that the ACS “stands by its recommendation that women 40 and over should receive annual mammography.” The ACS letter was written in response to the New York Times article, and on the same day. In that article, Brawley is quoted as saying, “We don’t want people to panic. But I’m admitting that American medicine has overpromised when it comes to screening. The advantages to screening have been exaggerated.”² The ACS response letter did not mention the New York Times quotes. The JAMA article surveyed results for both mammography and prostate-cancer screening, and its conclusion wrapped both tests together in calling for revised protocols. “Screening for breast and prostate cancers has increased the numbers of cancers detected, generating expense and morbidity from detection and treatment of cancers that pose minimal risk,” Esserman et al write. “To improve screening, a new focus is recommended for research and care to identify markers that discriminate minimal-risk from high-risk disease,” they add. “About $20 billion is spent to screen for breast cancer and prostate cancer in the United States. Highly innovative businesses typically invest 10% to 20% of their sales into research and development of the next new product. A similar investment is needed to improve screening, accelerate prevention research, and reduce harm from breast cancer and prostate cancer deaths.”¹The Real World In comments to the media following release of the JAMA article, Esserman charged that mammography screening was a poor tool for spotting aggressive cancers that can kill quickly. Bassett and Mendelson do not question that there are shortcomings in current mammography screening, but both emphasize that the screening tools to differentiate cancer types that Esserman calls for aren’t available yet. “What we need are chemical tests, and those can be obtained only by doing a core biopsy,” Bassett says. “How are you going to tell if the cancer is aggressive or not? I think the JAMA authors are talking about something way in the future. We’re not yet where we’re even close.” In the meantime, Bassett says, women need to get mammograms beginning at age 40. “I was just looking at all the biopsies from last week. There was a 44-year-old, doing her first screening, who showed a ductal carcinoma in situ that took up one-fourth of the breast. If it had been caught four years ago, it would probably have been curable. Now, we’ve got to screen her lymph nodes.” Mendelson says, “Esserman is a surgeon. She calls for blood tests. We’ve been looking for those for a long time. It would be wonderful if we had them, but we don’t.” Mendelson questions the timing of the JAMA article, coming, as it does, in the midst of the US health-reform debate. “I don’t know, but my whole thing is that this is a dollars-and-cents campaign here,” she says. “Everybody is talking about how much in arrears in health care the United States is, and where we can find money to cut. The European mammography guidelines start at age 50, are biennial, and cut off around 70, except for symptomatic women who get diagnostic exams. One would wonder if this article is not just laying the groundwork for undermining our very sensible guidelines, which establish mammography in the years between ages 40 and 50, where screening is much needed and appreciated,” she says. Mendelson urges women and their physicians to continue using current mammography protocols calling for screening beginning at age 40. “The takeaway for the patient is that she should not change her annual mammography screening at all,” she says. Mendelson vows to put the financing of mammography screening on the agenda of the ACR® economics committee and to raise the issue at the 2009 RSNA meeting. “We need something that will anticipate a fight we’re going to have to fight,” she says.